ABSTRACT
BACKGROUND: The Bundled Payment for Care Improvement initiative is a program designed by Center for Medicare and Medicaid Services in an attempt to increase the value of care delivered to Medicare recipients by rewarding providers who can deliver more cost-efficient, high-value care. This article reports the results of a coordinated care redesign program in an independent, medium-sized private-practice orthopedic group. METHODS: A committee of stakeholders worked to redesign care protocols for patients receiving upper and lower joint replacement procedures. These protocols included preoperative, intraoperative, and postoperative care. Baseline metrics for post-acute care and readmissions were compared to the same metrics after initiating care redesign. RESULTS: Incidence of discharge to inpatient facilities decreased as did length of stay at these facilities. Home health utilization and readmission rates were lowered. Average cost of the 90-day episodes decreased to a statistically significant degree. CONCLUSIONS: These initial results indicate that coordinated care redesign in the private practice setting can yield higher value care with decreased utilization of high-cost care, particularly in the post-acute period.
ABSTRACT
BACKGROUND: Total shoulder arthroplasty (TSA) is commonly used to treat glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. Recently, reverse shoulder arthroplasty (RSA) has been used for GHOA patients who are elderly or have eccentric glenoid wear. We evaluated patients with GHOA scheduled to have TSA but who were changed to RSA because of intraoperative difficulties with the glenoid component or instability and compared them with a cohort that underwent TSA to determine if the groups had similar outcomes. METHODS: We identified 24 consecutive GHOA patients who underwent RSA and matched them to 96 patients who underwent TSA. Glenoid wear and rotator cuff musculature were assessed with preoperative computed tomography scans. Direct hospital costs of the procedure were collected. RESULTS: Postoperative American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and range of motion were similar between the 2 groups. Five TSA patients had radiographic glenoid loosening, whereas no RSA patients did. Neither group required a revision. One RSA patient required surgery for treatment of a periprosthetic fracture. RSA was $7274 more costly than TSA, related mainly to implant cost. CONCLUSIONS: Patients with GHOA who were converted intraoperatively to RSA because of improper seating of the glenoid trial or persistent posterior subluxation had outcomes comparable to those of a similar group of patients in whom TSA was performed. At midterm follow-up, TSA is associated with lower cost than RSA. The higher rate of radiographic loosening in the TSA group warrants longer follow-up to assess revision costs. In cases in which a TSA cannot be performed with confidence, RSA is a reasonable alternative.
